CATHOLIC YOUTH ORGANIZATION
DIOCESE OF BROOKLYN/QUEENS
Covid-19 Screening Questionnaire
NAME *
DATE *
MM
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DD
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YYYY
GAME TIME *
Time
:
LOCATION *
PHONE NUMBER *
CHILD'S NAME (IF APPLICABLE)
POSTION (CYO STAFF/COACH/PAR/AD/OFFICIAL/PARENT/PLAYER) *
1. In the past 24 hours, have you or your child experienced a fever or any flu like symptoms? *
2. Have you or your child recently been in close contact with anyone who has exhibited any of the above symptoms? *
3. Have you or your child recently been in close contact with anyone who has tested positive for Covid-19? *
4. Have you or your child recently traveled to a restricted area according to New York State’s travel advisory? *
Certification
I hereby certify that the responses provided above are true and accurate to the best of my knowledge:
SIGNATURE *
DATE *
MM
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DD
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YYYY
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